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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600032
Report Date: 10/22/2022
Date Signed: 10/22/2022 03:45:19 PM


Document Has Been Signed on 10/22/2022 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:P & R RESIDENTIAL CARE (FOR ELDERLY)FACILITY NUMBER:
015600032
ADMINISTRATOR:SAN MIGUEL, PRECILLAFACILITY TYPE:
740
ADDRESS:32262 CREST LANETELEPHONE:
(510) 489-8082
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
10/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marta Dacuma, CaregiverTIME COMPLETED:
03:55 PM
NARRATIVE
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On 10/22/2022 at 1:50PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Marta Dacuma, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Pricella San MIguel via telephone and was given approval for Caregiver to sign documents.

Upon entry, LPA's temperature was not checked. LPA observed screening station in backyard and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, backyard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 137.2 degrees Fahrenheit. Fire extinguisher last serviced on 10/28/2021.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: P & R RESIDENTIAL CARE (FOR ELDERLY)
FACILITY NUMBER: 015600032
VISIT DATE: 10/22/2022
NARRATIVE
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 10/31/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC601E Emergency Disaster Plan
-Administrator certificate
-Facility roster

LPA observed the following deficiencies:

-At 2:10PM, LPA observed hot water temperature to be 137.2 in residents' shared bathroom.
-At 2:20PM, LPA staff S3 sleeping on a couch in locked shed in backyard.
-At 2:50PM, LPA observed that R1 and R2 did not have a doctor's order for the hospital bed.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 10/22/2022 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: P & R RESIDENTIAL CARE (FOR ELDERLY)
FACILITY NUMBER: 015600032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(b)
87305 Alterations to Existing Building or New Facilities

(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having an updated facility sketch showing shed being used for employees to sleep which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Administrator agreed to send updated facility sketch showing shed and LIC200 for fire clearance to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having a doctor's order for R1 and R2 to have a hospital bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Administrator agreed to obtain a doctor's for R1 and R2's hospital bed and submit a copy to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 10/22/2022 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: P & R RESIDENTIAL CARE (FOR ELDERLY)
FACILITY NUMBER: 015600032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on(observation, the licensee did not comply with the section cited above in having the hot water temperature at 137.2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Administrator agreed to adjust the hot water between 105. and 120. degrees Fahrenheit and submit a photo showing temperature
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2022
LIC809 (FAS) - (06/04)
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